The Emperor of All Maladies Read online

  At the Allgemeines Krankenhaus, the teaching hospital in Vienna where he was appointed a professor, Billroth and his students now began to master and use a variety of techniques to remove tumors from the stomach, colon, ovaries, and esophagus, hoping to cure the body of cancer. The switch from exploration to cure produced an unanticipated challenge. A cancer surgeon’s task was to remove malignant tissue while leaving normal tissues and organs intact. But this task, Billroth soon discovered, demanded a nearly godlike creative spirit.

  Since the time of Vesalius, surgery had been immersed in the study of natural anatomy. But cancer so often disobeyed and distorted natural anatomical boundaries that unnatural boundaries had to be invented to constrain it. To remove the distal end of a stomach filled with cancer, for instance, Billroth had to hook up the pouch remaining after surgery to a nearby piece of the small intestine. To remove the entire bottom half of the stomach, he had to attach the remainder to a piece of distant jejunum. By the mid-1890s, Billroth had operated on forty-one patients with gastric carcinoma using these novel anatomical reconfigurations. Nineteen of these patients had survived the surgery.

  These procedures represented pivotal advances in the treatment of cancer. By the early twentieth century, many locally restricted cancers (i.e., primary tumors without metastatic lesions) could be removed by surgery. These included uterine and ovarian cancer, breast and prostate cancer, colon cancer, and lung cancer. If these tumors were removed before they had invaded other organs, these operations produced cures in a significant fraction of patients.

  But despite these remarkable advances, some cancers—even seemingly locally restricted ones—still relapsed after surgery, prompting second and often third attempts to resect tumors. Surgeons returned to the operating table and cut and cut again, as if caught in a cat-and-mouse game, as cancer was slowly excavated out of the human body piece by piece.

  But what if the whole of cancer could be uprooted at its earliest stage using the most definitive surgery conceivable? What if cancer, incurable by means of conventional local surgery, could be cured by a radical, aggressive operation that would dig out its roots so completely, so exhaustively, that no possible trace was left behind? In an era captivated by the potency and creativity of surgeons, the idea of a surgeon’s knife extracting cancer by its roots was imbued with promise and wonder. It would land on the already brittle and combustible world of oncology like a firecracker thrown into gunpowder.

  * Hunter used this term both to describe metastatic—remotely disseminated—cancer and to argue that therapy was useless.

  A Radical Idea

  The professor who blesses the occasion

  Which permits him to explain something profound

  Nears me and is pleased to direct me—

  “Amputate the breast.”

  “Pardon me,” I said with sadness

  “But I had forgotten the operation.”

  —Rodolfo Figuoeroa,

  in Poet Physicians

  It is over: she is dressed, steps gently and decently down from the table, looks for James; then, turning to the surgeon and the students, she curtsies—and in a low, clear voice, begs their pardon if she has behaved ill. The students—all of us—wept like children; the surgeon happed her up.

  —John Brown describing a

  nineteenth-century mastectomy

  William Stewart Halsted, whose name was to be inseparably attached to the concept of “radical” surgery, did not ask for that distinction. Instead, it was handed to him almost without any asking, like a scalpel delivered wordlessly into the outstretched hand of a surgeon. Halsted didn’t invent radical surgery. He inherited the idea from his predecessors and brought it to its extreme and logical perfection—only to find it inextricably attached to his name.

  Halsted was born in 1852, the son of a well-to-do clothing merchant in New York. He finished high school at the Phillips Academy in Andover and attended Yale College, where his athletic prowess, rather than academic achievement, drew the attention of his teachers and mentors. He wandered into the world of surgery almost by accident, attending medical school not because he was driven to become a surgeon but because he could not imagine himself apprenticed as a merchant in his father’s business. In 1874, Halsted matriculated at the College of Physicians and Surgeons at Columbia. He was immediately fascinated by anatomy. This fascination, like many of Halsted’s other interests in his later years—purebred dogs, horses, starched tablecloths, linen shirts, Parisian leather shoes, and immaculate surgical sutures—soon grew into an obsessive quest. He swallowed textbooks of anatomy whole and, when the books were exhausted, moved on to real patients with an equally insatiable hunger.

  In the mid-1870s, Halsted passed an entrance examination to be a surgical intern at Bellevue, a New York City hospital swarming with surgical patients. He split his time between the medical school and the surgical clinic, traveling several miles across New York between Bellevue and Columbia. Understandably, by the time he had finished medical school, he had already suffered a nervous breakdown. He recuperated for a few weeks on Block Island, then, dusting himself off, resumed his studies with just as much energy and verve. This pattern—heroic, Olympian exertion to the brink of physical impossibility, often followed by a near collapse—was to become a hallmark of Halsted’s approach to nearly every challenge. It would leave an equally distinct mark on his approach to surgery, surgical education—and cancer.

  Halsted entered surgery at a transitional moment in its history. Bloodletting, cupping, leaching, and purging were common procedures. One woman with convulsions and fever from a postsurgical infection was treated with even more barbaric attempts at surgery: “I opened a large orifice in each arm,” her surgeon wrote with self-congratulatory enthusiasm in the 1850s, “and cut both temporal arteries and had her blood flowing freely from all at the same time, determined to bleed her until the convulsions ceased.” Another doctor, prescribing a remedy for lung cancer, wrote, “Small bleedings give temporary relief, although, of course, they cannot often be repeated.” At Bellevue, the “internes” ran about in corridors with “pus-pails,” the bodily drippings of patients spilling out of them. Surgical sutures were made of catgut, sharpened with spit, and left to hang from incisions into the open air. Surgeons walked around with their scalpels dangling from their pockets. If a tool fell on the blood-soiled floor, it was dusted off and inserted back into the pocket—or into the body of the patient on the operating table.

  In October 1877, leaving behind this gruesome medical world of purgers, bleeders, pus-pails, and quacks, Halsted traveled to Europe to visit the clinics of London, Paris, Berlin, Vienna, or Leipzig, where young American surgeons were typically sent to learn refined European surgical techniques. The timing was fortuitous: Halsted arrived in Europe when cancer surgery was just emerging from its chrysalis. In the high-baroque surgical amphitheaters of the Allgemeines Krankenhaus in Vienna, Theodor Billroth was teaching his students novel techniques to dissect the stomach (the complete surgical removal of cancer, Billroth told his students, was merely an “audacious step” away). At Halle, a few hundred miles from Vienna, the German surgeon Richard von Volkmann was working on a technique to operate on breast cancer. Halsted met the giants of European surgery: Hans Chiari, who had meticulously deconstructed the anatomy of the liver; Anton Wolfler, who had studied with Billroth and was learning to dissect the thyroid gland.

  For Halsted, this whirlwind tour through Berlin, Halle, Zurich, London, and Vienna was an intellectual baptism. When he returned to practice in New York in the early 1880s, his mind was spinning with the ideas he had encountered in his journey: Lister’s carbolic sprays, Volkmann’s early attempts at cancer surgery, and Billroth’s miraculous abdominal operations. Energized and inspired, Halsted threw himself to work, operating on patients at Roosevelt Hospital, at the College of Physicians and Surgeons at Columbia, at Bellevue, and at Chambers Hospital. Bold, inventive, and daring, his confidence in his handiwork boomed. In 1882, he removed
an infected gallbladder from his mother on a kitchen table, successfully performing one of the first such operations in America. Called urgently to see his sister, who was bleeding heavily after childbirth, he withdrew his own blood and transfused her with it. (He had no knowledge of blood types; but fortunately Halsted and his sister were a perfect match.)

  In 1884, at the prime of his career in New York, Halsted read a paper describing the use of a new surgical anesthetic called cocaine. At Halle, in Volkmann’s clinic, he had watched German surgeons perform operations using this drug; it was cheap, accessible, foolproof, and easy to dose—the fast food of surgical anesthesia. His experimental curiosity aroused, Halsted began to inject himself with the drug, testing it before using it to numb patients for his ambitious surgeries. He found that it produced much more than a transitory numbness: it amplified his instinct for tirelessness; it synergized with his already manic energy. His mind became, as one observer put it, “clearer and clearer, with no sense of fatigue and no desire or ability to sleep.” He had, it would seem, conquered all his mortal imperfections: the need to sleep, exhaustion, and nihilism. His restive personality had met its perfect pharmacological match.

  For the next five years, Halsted sustained an incredible career as a young surgeon in New York despite a fierce and growing addiction to cocaine. He wrested some control over his addiction by heroic self-denial and discipline. (At night, he reportedly left a sealed vial of cocaine by his bedside, thus testing himself by constantly having the drug within arm’s reach.) But he relapsed often and fiercely, unable to ever fully overcome his habit. He voluntarily entered the Butler sanatorium in Providence, where he was treated with morphine to treat his cocaine habit—in essence, exchanging one addiction for another. In 1889, still oscillating between the two highly addictive drugs (yet still astonishingly productive in his surgical clinic in New York), he was recruited to the newly built Johns Hopkins Hospital by the renowned physician William Welch—in part to start a new surgical department and in equal part to wrest him out of his New York world of isolation, overwork, and drug addiction.

  Hopkins was meant to change Halsted, and it did. Gregarious and outgoing in his former life, he withdrew sharply into a cocooned and private empire where things were controlled, clean, and perfect. He launched an awe-inspiring training program for young surgical residents that would build them in his own image—a superhuman initiation into a superhuman profession that emphasized heroism, self-denial, diligence, and tirelessness. (“It will be objected that this apprenticeship is too long, that the young surgeon will be stale,” he wrote in 1904, but “these positions are not for those who so soon weary of the study of their profession.”) He married Caroline Hampton, formerly his chief nurse, and lived in a sprawling three-story mansion on the top of a hill (“cold as stone and most unlivable,” as one of his students described it), each residing on a separate floor. Childless, socially awkward, formal, and notoriously reclusive, the Halsteds raised thoroughbred horses and purebred dachshunds. Halsted was still deeply addicted to morphine, but he took the drug in such controlled doses and on such a strict schedule that not even his closest students suspected it. The couple diligently avoided Baltimore society. When visitors came unannounced to their mansion on the hill, the maid was told to inform them that the Halsteds were not home.

  With the world around him erased and silenced by this routine and rhythm, Halsted now attacked breast cancer with relentless energy. At Volkmann’s clinic in Halle, Halsted had witnessed the German surgeon performing increasingly meticulous and aggressive surgeries to remove tumors from the breast. But Volkmann, Halsted knew, had run into a wall. Even though the surgeries had grown extensive and exhaustive, breast cancer had still relapsed, eventually recurring months or even years after the operation.

  What caused this relapse? At St. Luke’s Hospital in London in the 1860s, the English surgeon Charles Moore had also noted these vexing local recurrences. Frustrated by repeated failures, Moore had begun to record the anatomy of each relapse, denoting the area of the original tumor, the precise margin of the surgery, and the site of cancer recurrence by drawing tiny black dots on a diagram of a breast—creating a sort of historical dartboard of cancer recurrence. And to Moore’s surprise, dot by dot, a pattern had emerged. The recurrences had accumulated precisely around the margins of the original surgery, as if minute remnants of cancer had been left behind by incomplete surgery and grown back. “Mammary cancer requires the careful extirpation of the entire organ,” Moore concluded. “Local recurrence of cancer after operations is due to the continuous growth of fragments of the principal tumor.”

  Moore’s hypothesis had an obvious corollary. If breast cancer relapsed due to the inadequacy of the original surgical excisions, then even more breast tissue should be removed during the initial operation. Since the margins of extirpation were the problem, then why not extend the margins? Moore argued that surgeons, attempting to spare women the disfiguring (and often life-threatening) surgery were exercising “mistaken kindness”—letting cancer get the better of their knives. In Germany, Halsted had seen Volkmann remove not just the breast, but a thin, fanlike muscle spread out immediately under the breast called the pectoralis minor, in the hopes of cleaning out the minor fragments of leftover cancer.

  Halsted took this line of reasoning to its next inevitable step. Volkmann may have run into a wall; Halsted would excavate his way past it. Instead of stripping away the thin pectoralis minor, which had little function, Halsted decided to dig even deeper into the breast cavity, cutting through the pectoralis major, the large, prominent muscle responsible for moving the shoulder and the hand. Halsted was not alone in this innovation: Willy Meyer, a surgeon operating in New York, independently arrived at the same operation in the 1890s. Halsted called this procedure the “radical mastectomy,” using the word radical in the original Latin sense to mean “root”; he was uprooting cancer from its very source.

  But Halsted, evidently scornful of “mistaken kindness,” did not stop his surgery at the pectoralis major. When cancer still recurred despite his radical mastectomy, he began to cut even farther into the chest. By 1898, Halsted’s mastectomy had taken what he called “an even more radical” turn. Now he began to slice through the collarbone, reaching for a small cluster of lymph nodes that lay just underneath it. “We clean out or strip the supraclavicular fossa with very few exceptions,” he announced at a surgical conference, reinforcing the notion that conservative, nonradical surgery left the breast somehow “unclean.”

  At Hopkins, Halsted’s diligent students now raced to outpace their master with their own scalpels. Joseph Bloodgood, one of Halsted’s first surgical residents, had started to cut farther into the neck to evacuate a chain of glands that lay above the collarbone. Harvey Cushing, another star apprentice, even “cleaned out the anterior mediastinum,” the deep lymph nodes buried inside the chest. “It is likely,” Halsted noted, “that we shall, in the near future, remove the mediastinal contents at some of our primary operations.” A macabre marathon was in progress. Halsted and his disciples would rather evacuate the entire contents of the body than be faced with cancer recurrences. In Europe, one surgeon evacuated three ribs and other parts of the rib cage and amputated a shoulder and a collarbone from a woman with breast cancer.

  Halsted acknowledged the “physical penalty” of his operation; the mammoth mastectomies permanently disfigured the bodies of his patients. With the pectoralis major cut off, the shoulders caved inward as if in a perpetual shrug, making it impossible to move the arm forward or sideways. Removing the lymph nodes under the armpit often disrupted the flow of lymph, causing the arm to swell up with accumulated fluid like an elephant’s leg, a condition he vividly called “surgical elephantiasis.” Recuperation from surgery often took patients months, even years. Yet Halsted accepted all these consequences as if they were the inevitable war wounds in an all-out battle. “The patient was a young lady whom I was loath to disfigure,” he wrote with genuine concern, des
cribing an operation extending all the way into the neck that he had performed in the 1890s. Something tender, almost paternal, appears in his surgical notes, with outcomes scribbled alongside personal reminiscences. “Good use of arm. Chops wood with it . . . no swelling,” he wrote at the end of one case. “Married, Four Children,” he scribbled in the margins of another.

  But did the Halsted mastectomy save lives? Did radical surgery cure breast cancer? Did the young woman that he was so “loath to disfigure” benefit from the surgery that had disfigured her?

  Before answering those questions, it’s worthwhile understanding the milieu in which the radical mastectomy flourished. In the 1870s, when Halsted had left for Europe to learn from the great masters of the art, surgery was a discipline emerging from its adolescence. By 1898, it had transformed into a profession booming with self-confidence, a discipline so swooningly self-impressed with its technical abilities that great surgeons unabashedly imagined themselves as showmen. The operating room was called an operating theater, and surgery was an elaborate performance often watched by a tense, hushed audience of observers from an oculus above the theater. To watch Halsted operate, one observer wrote in 1898, was to watch the “performance of an artist close akin to the patient and minute labor of a Venetian or Florentine intaglio cutter or a master worker in mosaic.” Halsted welcomed the technical challenges of his operation, often conflating the most difficult cases with the most curable: “I find myself inclined to welcome largeness [of a tumor],” he wrote—challenging cancer to duel with his knife.

  But the immediate technical success of surgery was not a predictor of its long-term success, its ability to decrease the relapse of cancer. Halsted’s mastectomy may have been a Florentine mosaic worker’s operation, but if cancer was a chronic relapsing disease, then perhaps cutting it away, even with Halsted’s intaglio precision, was not enough. To determine whether Halsted had truly cured breast cancer, one needed to track not immediate survival, or even survival over five or ten months, but survival over five or ten years.